The TKA Experience

"A total knee replacement : an orthopedic surgeon as the patient"

I am an orthopaedic surgeon who does not do joint replacements, but I am consulted on a daily basis by patients who need a TKA and have many unanswered questions. Not because their orthopaedic surgical team did not want to answer the questions, but rather, the patient just didn't know what to ask the team. I have several goals for writing about my experience as a patient undergoing total knee replacement. Most importantly, to share my experience at a center devoted to joint replacement. I hope that I will answer many questions and stimulate others. I promise I will be honest about the struggles that occur during the postoperative course. As a Professor in the 2016 number one USA program in physical therapy, University of Delaware, Physical Therapy - UDPT, I am biased about the importance of exercising to get ready for the surgery (Pre-hab) and the need to get and maintain strength and range of motion after surgery.

I will explain how I delayed knee replacement for more than 8 years while maintaining an active lifestyle, why my orthopaedic surgeon and I preferred the knee chosen and, how I decided it was safe to drive again after surgery. I will explain the skin and shower protocol in the day prior to surgery, medicines given the day of surgery to avoid infections, and the medicines I took after surgery to avoid constipation and blood clots.

Many total joint replacement patients have other medical problems. While I don't have diabetes, I do have vein issues in my surgical leg and a sensitive stomach preventing me from taking anti-inflammatory pills for more than 2 or 3 days. I will offer how my “special needs” may vary from the normal course for other patients.

If my patients and others who read my accounts do not find my shared information both helpful and at times amusing, oh well, I tried.

Sincerely Michael J. Axe M.D.

On my birthday, August 2, 1971 I injured my right knee during a football practice drill in preparation for the Pennsylvania Big 33 game. I felt a pop deep in my knee, and developed some mild swelling in my knee overnight. This game was to be played in 3 days, and it was very important to me, so I told no one. I used the ice whirlpool, and bought a knee brace at a local drugstore and never missed a practice.

I was able to limit my play to just offensive guard and avoided defense and special teams. After playing this game, I left for the second All-Star game and 7 days later I played on both offense and defense. While I continued to have mild swelling, with the help of a canvas brace with two metal side pieces and ice whirlpool, "I coped.” Three weeks later, I started college freshman football and started every game that season and for the next 3 varsity seasons, totaling 100 consecutive starts in my football career.

It was a medical school volleyball game which led to my first surgery to remove my inner (medial) meniscus. I was later told my ACL (anterior cruciate ligament) had been injured and it had attached to the ligament nearby( PCL). I recovered nicely from open, 2 incision surgery, and returned to all activities including playing basketball almost weekly during my orthopaedic residency at the University of Pittsburgh. I did well until my 40th birthday party, when I injured my outside (lateral) meniscus playing basketball. X-rays revealed an almost normal knee then, but my knee was anything but normal feeling unstable and giving way regularly. Despite a strengthening program, I could no longer trust it for twisting activities. X-rays every few years saw the joint space narrow, and the lower leg (tibia) shifting outwards on the bone above (femur). At 55, my x-ray showed the need for joint replacement (Fig 2).

As an orthopaedic surgeon, I had access to all arthritic remedies around the world. As a very big believer in hyaluronic acid, every 3 months since age 50, I had been receiving injections of first Hyalgan and then Supartz.(Fig 3) Both are very commonly used hyaluronic acids coming in 2cc syringes to be given 3 or 5 times every 6 months.

At age 55, my knee began to swell, requiring fluid removal and cortisone type injections, and sometimes simultaneously injecting it with hyaluronic acid. It took almost 2 years to control the swelling. I was unable to take anti-inflammatories more than a day or two in a row due to my sensitive stomach, so I developed an interest in rub-ins (topicals). These creams or gels (Fig 4) are applied onto the skin at the site of pain and swelling and are rubbed into the painful area, thus avoiding stomach issues.

I've tried sleeve garments with electrical currents and muscle stimulation for pain control with moderate to very good success. While trying special bracing to unload and stabilize my knee, I found these braces cumbersome and uncomfortable but I probably never gave them a chance to work.(Fig 5).

Now at age 63, my ability to walk fast, walk far, and climb steps has markedly decreased as shown on my UD Arthritis Performance Profile. My quadriceps strength had markedly decreased, although with 9 months of intense work, I strengthened my right lower extremity to be stronger than my “good” left knee. Despite this, I was still severely limited on uneven surfaces, a problem encountered on my frequent speaking engagements throughout the world. Regarding recreational activities, once I was unrestricted dancing, now I had lost a step or two. It was very clear to me I had failed non-operative management. It was time despite claims of dramatic improvement guarantees. (Fig 6)

Prehab; getting ready for a TKA

Knowing that a TKA will take its toll on the entire leg, I continue to emphasize the importance of the concept of prehab, rehabilitation prior to the operation. While maintaining range of motion and keeping my legs strong had been important in reducing pain and delaying the need for my TKA for years, I still began a 60 day program prior to my surgery. In addition to my elliptical workout and walking totaling more than 10,000 steps per day, I did daily exercises to include two sets of 50 hip abduction "clamshells" (Fig 7), and 200 crunches. Every other day I added to my base program, 2 sets of single 25 repetitions leg extension and 2 sets of 25 repetitions dumbbell raises for my arms and shoulders, resting 1 minute between sets.

I anticipated that I would be using a walker, then crutches, and then a cane for postoperative walking. As I travel the world, speaking and attending conferences, the only people using axillary (armpit) crutches rather than the more sensible forearm crutches (Lofstrands) (Fig 8) were silly Americans. Forearm crutches allow backpack wear, avoid nerve compression, and are easier to use getting in and out of cars. My recommendation, as a sports orthopedist, is to use forearm crutches if the patient is going to require crutches for more than 2 weeks. My physical therapy colleagues strongly agree with me. Axillary crutches are at risk to pressure nerves in the armpit and make carrying anything, including backpacks, very difficult. While forearm crutches can be slightly more expensive, they are worth the added cost and are available in the offices of First State Orthopaedics.

Finding the right orthopaedic surgeon to do my knee replacement was very easy. We have many qualified surgeons at FSO. I have great respect for all of them, including my son Dr. Jeremie Axe (Fig 9). I chose Dr. Leo Raisis (Fig 10), my longtime orthopaedic partner, and at that time, Chair of the Advanced Total Joint Center at Christiana Care Hospital System. He has encouraged his patients to be rehabilitated at the University of Delaware, Department of Physical Therapy Clinic. At UDPT, many of his patients have been like myself, part of many arthritis research projects. He believes in early physical therapy and has been an advocate of outcomes-based change. I have seen no better results than his in our community nor in the published literature from patients throughout the world.

Office Visit

Dr. Raisis performs many hundreds of TKA's per year. He has a very well oiled office machine. He expects his patients to be well-informed. To assure this, he has excellent office handouts to guide questions and expectations. All of his TKA patients will have failed therapeutic injection and at least 8 visits of physical therapy. No patient will be scheduled within 12 weeks of an injection because of the increased likelihood of infections (although small). We discussed why he preferred the Zimmer Persona knee (Fig 11) over others that are available. In his hands the results are most reproducible and most patients have more than 120 degrees of flexion and full extension after surgery and rehabilitation. The Persona has all sizes necessary to fit a knee. His preferred incision allowed my muscle to be split off of my knee cap rather than cutting into the tendon; thereby hopefully allowing an easier regaining of motion. To reduce postoperative pain, he injects the joint with a special solution of anesthetics to help relieve some pain and tranexamic acid to reduce the bleeding. He does not use a drain. He uses absorbable stitches deep into the skin and closes the skin with staples. He uses aspirin to reduce the likelihood of blood clots for all people who do not have increased risk factors. I don't smoke and I am proud to say that I have never smoked a cigarette. I have no history myself, nor my family, of blood clotting problems. I don't nor ever have taken birth control pills. (This is a true statement, but it is also an effort at humor). He emphasized the importance of having my leg above heart level to lessen the likelihood of leg swelling. He further emphasized the importance of taking my pain medicine so that I could do my exercises and the importance of taking my laxative and stool softeners to prevent constipation from the side effects of the pain medication. Due to his large demand, patients should expect at least a 6 week wait from the decision to have surgery to the actual time of the surgery. Many things will happen during the 6 weeks. I had my yearly physical examination with my family physician (Fig 12), although for me it had been much longer than a year. At that time, I had the necessary blood work for surgery, EKG, and received medical clearance that certified I was healthy enough to undergo the rigors of the procedure. Due to varicosities and a slow to heal wound on my ankle, I had undergone tests for Diabetes, arterial and venous insufficiency. All were negative. I would like to thank Vascular Lab Supervisor Tony Gialoretto, and Vascular Tech Greg Rhland for accommodating my hours taking care of patients by making special time for me to have these pre-op tests and not making my patients wait.

Christiana Care Advanced Total Joint Center Visit

Three weeks before the scheduled week of surgery, it is recommended that the patient come into the Joint Center for an extremely informative 2 hours. I was to bring the CCHS Advanced Total Joint Center notebook (Fig 13) given to me by Dr. Raisis and to have read it. At that time, the total joints team would evaluate my past medical history and explain in detail what the patient should expect during their short stay in the hospital joint center. The caregiver is also encouraged to attend. No 2 hours could be better spent even for someone like myself who has a very good knowledge of medical care. At the same visit patients were given the opportunity to meet the physician who will be taking care of their medical needs during their hospital stay. There are 3 physicians that provide the service at the hospital and they rotate weekly. By coming in 3 weeks in advance, patients actually meet the primary care physician who will be taking care of them during their hospital stay. Mine was Dr. Tim Hennessy (Fig 14). While I knew him professionally, it was great to meet him personally. I subsequently would see him right after surgery and the next day prior to my discharge. While my hospital course was uneventful I can assure you those 2 hours at this pre-op visit, added to my super hospital experience. The Joint Center Staff know their jobs and it is obvious that they love their job. While I know there are several area joint centers within 100 miles of the Wilmington Hospital, I cannot imagine any better. I left that Wednesday morning visit with a complete understanding of what to expect from the time I left my car in the patient circle prior to admission, to when and where I would be picked up at the time of discharge. The added Joint Center handouts on medications were very helpful and no question was left unanswered.

Pre- op visit with Emma/Dr. Raisis‘s P.A.

With surgery scheduled and only a week away, I met with Emma Kaplan P.A.C (Fig 15) to discuss specifics. While I had asked specific surgical questions to Dr. Raisis, this gave me an opportunity to ask the ones I missed, and any others that I had thought of since the earlier visit with him. She reinforced the need for me to take my pain medication and my constipation medication. I could shower in 24 hours as long as I did not soak the incision underwater. In Dr. Raisis's experience, aspirin had been all that was necessary to prevent blood clots. The most important point made on this visit was not to place a pillow under my knee and to keep my leg above my heart to reduce leg swelling. All my question answered, I walked back up the hall to my side of patient exam rooms and completed my patient office hours at FSO.

Pre-Surgery Night.

While I did not expect any problems, and was in good health, I was sure to make it clear to my family that should any unforeseen problem occur, what my expectations were and I checked my will and power of attorney. I watched the college football bowl games and ate nachos. I took a shower and then used my skin wipes given to me at the Joint Center pre-op visit and Theraworx (Fig 16). Earlier that day I had changed the sheets in my bed, and I had packed my hospital bag. I set my alarm for 4:30 a.m. and retired at 10 p.m. and slept well.

Surgery day

I awoke to the alarm having slept soundly. After brushing my teeth, I was able to have a bowel movement. I had been taking Myralax the two days prior to hopefully clear any excess from my G.I. system. I got dressed in my loosely fitting clothing, packed the car with my change of clothes and my walker and drove with my significant other (Fig 17), who is also my care giver/physical therapist to the hospital. As instructed in my preoperative hospital visit, I park in valet parking, went to the south elevator and got off on the third floor-Joint Center Admissions (Fig 18). As instructed I arrived one and one half hour before my surgery time. My identification, paperwork and site of operation was verified and I was given a wristband.

I was taken to the pre-op area where my name, surgeon, and operative site were verified again. I was asked to remove my clothes and to change into a gown. Both Dr. Raisis and Emma saw me in the pre-operative area. Again verifying the operative site, Emma and I signed my leg. This is part of the pre-operative protocol. Both the surgeon or PA, as well as the patient signs the operative side. An IV was started. My anesthesiologist, Dr. Pablo Adler (Fig 18B), explained to me what he was going to do during my spinal anesthesia. He assured me despite my size, and my previous back problem he did not anticipate any problems. In fact, in the past, he was able to do spinal anesthesia on patients who had spinal deformity as well as those who have had spinal fusions. He told me I had less than 1% chance of having any adverse reactions to the spinal to include headache. He gave me IV sedation, and with the help of my nurse anesthetist, they helped me into a sitting position on the side of the bed. I felt a small stick from the Lidocaine injection, and within seconds, the spinal was in and I was returned to my back. I don't remember going to the operating room. One of the biggest concerns about a total knee replacement is the risk of infection. To help prevent this, each nostril (Fig 19) was swabbed twice with Provadione for 30 seconds to total 2 minutes and 1 hour prior to my surgery, my IV antibiotics were begun.

Operating Room

I really don't remember much in the operating room. I remember Dr. Raisis and Emma saying hello again, and the next thing I remember was Dr. Raisis saying the surgery went well as the drapes were being removed from my leg. I remembered John, the second PA, answering my question about how much flexion I had. It was 120 degrees. As previously told to me, Dr. Raisis had used a central incision on the skin, a muscle splitting deep incision, and cemented the three components into my knee. My capsule and tendon were closed with large absorbable sutures, the subcutaneous tissue in layers with smaller absorbable sutures, and my skin was stapled. He injected my knee with a combination of medications to include anesthetics and Tranexamic acid to reduce bleeding within the joint, and applied a sterile dressing. I briefly remember being returned to the pre-op area, speaking to Dr. Raisis and being transported to my single room by two large men discussing the college football bowl games. I was too drugged to get involved in the conversation of Alabama vs. Clemson.

Hospital Room

The room had both a bed and a reclining chair. The nurses did their standard protocol for checking vital signs to include my sensation. They gave me some crackers to eat since I was hungry and had absolutely no nausea. They applied TED stockings and the cooling unit to my right knee.The spinal anesthesia had completely worn off by noon. I was able to achieve 115 degrees of flexion. Physical therapy began early afternoon. (Fig 20) I was able to walk with a walker with weight bearing as tolerated with my physical therapist, Jen. I had no pain. Then I was returned to my reclining chair, and I was able to bend the knee 115 degrees. Several of my partners and FSO staff, including Dr. Raisis (Fig 21) and Emma stopped by to check on me and to give me my prescriptions. Lynn took them to the pharmacy (Fig 22) to be filled that evening. It was good that she did since the line was long and she had to go to another pharmacy. The one across the street from our house did not have the pain medication in stock. I was hungry at dinnertime, and while a liquid dinner was offered, I opted for a great sandwich from the Blue Crab Grill (Fig 23) I could only eat half my sandwich.

The medical staff the entire time I was there were appropriately attentive. They were there when I needed them, answered my bell within seconds, but they were not bothersome. Dr. Hennessy came to see me post-op. He assured me that he would be available by phone all night should I have any difficulties. The nurses gave me my medications as per Dr. Raisis's protocol, to include pain medication, anti-inflammatory, and blood thinner (aspirin). I was also receiving IV Toredol, every 8 hours. During the night, I awoke every 2 to 3 hours and received my pain medication.

Postop Day 1

After I had blood drawn (my H&H fell from 13.4 pre-op to 12.4), I did my breathing treatments, I got up out of bed with the nursing assistant, went to the bathroom and was able to have a bowel movement, I brushed my teeth, and returned to the reclining chair. I ate breakfast, and then was taken to physical therapy on the same floor. It was group physical therapy for all the people that had had surgery by Dr. Raisis the day before. Four of us had total knees and 2 had total hips. They reviewed how to walk with a walker, do our home exercises for our knees and hips, go up and down stairs, and how to get in and out of the passenger seat of a car. I progressed very fast, and was given the opportunity to be discharged in the morning thereby skipping the normal second physical therapy visit that afternoon prior to discharge.

Discharge Instructions

My discharge instructions were discussed with me by the nursing staff. Emma changed my dressing and ask if I had any further questions. I was taken to the pickup parking circle (Fig 24), helped into the passenger side of the car, and was off to Lewes.

We had arranged the furniture the week prior. The rugs and been taken up and the end tables moved. The foldout couch was prepared to include a pillow beneath the mattress that would allow my leg to be elevated above my heart (Fig 25). This elevation would prove to be very important to the speed of my recovery. For 23/24 hours for the next 3 days, I was in this position (Fig 26). I had a bedside urinal and commode (fortunately I never had to use it). I watched a lot of movies and binged watched several TV series. I used my walker from the car to the bed, changed into my PJ's, took my pain medication and began drinking fluids. More ice was placed into my machine. We had bought several bags of ice in advance and placed them in the freezer, so that we always had ice available. Every 4 hours, I did my calf pumps, quad sets and glut sets, as instructed by my physical therapists in the hospital, and my breathing treatments with my spirometer (Fig 27). Four times a day, I used my home muscle stimulation unit on my quadriceps for 15 minutes). (Fig 28). I took my pain medication, my stool medication, my sleeping pill, my aspirin, and retired to the bed room. My hospital bed also had an elevated bottom (Fig 29). We owned it, but normally others would have had to rent it. I fell asleep about 10 p.m. I woke up at 2 a.m., and I took more pain medication went back to sleep and slept until 6 a.m.

Postop Day 2

I awoke and took all my pills to include a prune juice and milk of magnesia cocktail. This was horrible and I like prunes. I got up, did my home exercises and walked 200 yards with my walker 4 times that day bearing as much weight as possible (almost 100%). I removed my dressing, treated my skin incision with Theraworx (Fig 30). I was able to bend my knee to 90 degrees but I had fullness in my thigh that I found to be very limiting. It felt as if I'd just played a football game and got hit in the thigh. While I had no swelling in my calf, I had been wearing TED stockings since surgery and I had my leg elevated all night. My thigh was 5 cm bigger on my surgery side. I massaged my thigh with over-the-counter Aspercream and combined it with over-the-counter Lidocaine rub. Late in the afternoon I was able to have a bowel movement. Both during walking, and with my foot elevated with my knee in full extension, I had significant pain in the back of my knee. I attributed this to the stretch of the capsule in the back of my knee. I had not had full extension for many years and now I had extension that was more than 0 degrees. I found that my walker walking and home exercises were easier if I took my pain medication one hour before trying to do them. While I was permitted to take a shower, I elected not to do so until postop day 3. I did my home exercise program 3 more times that day including muscle stim. I retired to bed at 10 p.m. after taking my pain and sleeping pills.

Postop Day 3

I awakened at 2 a.m. and took more pain medication and awoke at 6 a.m. after having a very restful night. I felt clear headed. I repeated my a.m. medications. One hour later I did my home exercise program, stimulated my quadriceps with my home unit and I did my walker walks. I returned to the couch and began another day of television, replacing my ice every 4 hours and keeping my leg elevated. Despite my exercises I could only flex my knee 85 degrees due to the tightness in my thigh. I still required my pain medication every 3 to 4 hours. I did have to be constantly reminded to keep my leg straight and not to place anything under my knee, although I REALLY wanted to. I had no swelling in my calf, but my thigh size difference was 8 cm. In the afternoon I took a shower. Fortunately the bathroom was handicapped equipped with hand rails (Fig 31) which made it easier for using the toilet and also the shower. The hand held attachment made it much easier for me to sit while showering. Showering did make me feel much better. I did eat but my appetite was still minimal. I forced myself to drink fluids. It worked. I had to use the bedside urinal often. I retired to the bedroom at 10 p.m. after taking all of my medication. This was a rough day. I required my pain medication every 2 to 3 hours. I had great difficulty getting comfortable. My thigh was bothersome despite massaging with Aspercream. I had been warned that the third day was the roughest, and it was.

Postop Day 4

I did not sleep well awakening every 2 to 4 hours but I did stay in bed till 8 a.m. I was able to do bed hangs to 85 degrees. I did my same home exercise program 4 times a day remembering to take my pain medication 1 hour prior. I continued to use my muscle stimulation machine increasing the amps over the day before. My appetite was slightly improved. I found sitting on the toilet much easier. The stool medication worked. I was able to stretch my pain medication back to 3 to 4 hours. I napped a few hours during the day. I took my evening medications and retired to the bedroom at 10 p.m.

Postop Day 5 (Day of the clicks)

I had added Tylenol PM to assist me in sleeping the night before and I had a good night sleep awakening only once at 3 a.m. for more pain medication. I call this the day of the clicks because it was the first time I felt any clicking in my knee. I couldn't tell where it was coming from, but I had been warned that when the clicks came they would be painless and could last up to 6 months. I did my same exercise routine, but I was losing flexion. While I only used the wheelchair sparingly the first several days, I found that I could use it to help me to gain flexion by forcibly holding my knee in a more flexed position and then backing off the wheelchair. (Fig 33) I was able to bend to 100 degrees of flexion that day. My thigh girth difference was now just 4 cm different. I noticed I had painless black and blue discoloring in the back of my knee. I had no shortness of breath or calf tenderness. I attributed this to blood pooling from me keeping my leg up. My exercises were uneventful with my knee cap moving well. My appetite was improving, I showered uneventfully, still sitting. Four times that day I used muscle stim at 3 quarters of the units total power outage. I really had cabin fever from being trapped inside for 5 days on my back.

Postop Day 6

I slept well from 10 p.m. until 6:30 a.m. requiring no pain medication. I had a good appetite that morning, ate well and took my morning medications. I did one series of walker walking, my home exercises, and I was able to use the muscle stimulation units on its maximum. I was able to shower standing. That afternoon, I was driven to Premier Physical Therapy where I had a good gait, and a knee range of motion of 2 degrees to 95 degrees. My care giver/home physical therapist had done a great job. I was able to get around on the bike for 10 minutes, did leg presses and standing knee extensions. My thigh girth was 4 cm difference. The retrograde lymphatic massage (Fig 34) really made my thigh feel better then and for the next several days. I continued to treat my incision three times a day with Theraworx. I did my home exercise program three more times that day to include muscle stim. I passed the Delaware Don't Drive Test. I did take my pain medication just prior to going to physical therapy, and I was glad I did. I took my evening medication and retired at 10 p.m. I slept well despite having physical therapy. I had been warned to expect difficulty sleeping that night.

Postop Day 7

I slept well that evening for 8 hours and did not require pain medication during the night. My bed hangs the next morning was an easy 90 degrees. It was the first day I was able to sit on the toilet comfortably. I continued to take the prune juice cocktail. It is worth noting that since my surgery I had no instability and no thrust while walking. This was for the first time in several years. I continued to wear my TED stockings when up and walking. I was full weight bearing and no longer needed my walker. I did use a cane in case I lost my balance. I continued to do my home exercises 4 times a day with muscle stimulation on maximum each time. I increased my amount of walking to 300 yards per session. It was noteworthy that the muscle stimulation unit required changing the 2 alkaline batteries after every 3 uses. I continued to ice for 30 minutes after each exercise bout. I did not like the stiffness associated with icing. I continued to take my pain medicine prior to exercise. We went to the movies and we sat in the special handicapped seats designed to give more leg room. I did have to get up every 30 minutes and walk. I continued to use the wheelchair to gain more flexion and used sit to stand exercises for a one minute warm-up. Even without a cane, my gait was nearly normal. I passed the DDD Test again. I took my evening medication and retired at 10 p.m. to a REGULAR bed.

Postop Day 8

I had a restless night but I spent 8 hours in bed. My bed hangs the next morning were 95 degrees. I had no leg edema but my thigh was still swollen with a difference of 6 cm. I was able to pass my don't drive test in 6.9 seconds. My incicision was clean but I continued to treat it with Theraworx. I sat comfortably on the commode and felt comfortable showering while standing. I did 2 sets of home exercises and muscle stimulation. I attended formal physical therapy again enjoying the retrograde massage. My exercise program was increased and my seat position on the bike was lowered 2 inches. At the end of physical therapy I was able to flex 100 degrees, and I felt well enough to have company for dinner. I slept in a regular bed and I took my evening medication and retired at 10 p.m.

Postop Day 9

I slept poorly. My incision was itchy and the staples were starting to pull on my skin. My hanging flexion was 95 degrees. I traveled in the passenger seat 1 1/2 hours from Rehoboth to Newark. Despite having the seat pushed back, I still felt very stiff in both my thigh and knee. I used muscle stimulation before and after the trip. I could comfortably sit on a traditional toilet. I again passed the Delaware Don't Drive Test. I began using the elliptical at level VII for 1 mile (Fig 35). It should be noted how deconditioned I was. Normally my heart rate would be 105 at this level. It was 136. I did 25 sit-ups for two sets as well as my other home exercises . My incision was itchy and the staples continued to pull on my skin. I was able to flex to just 95 degrees. I held my pain medication at dinner opting for a glass of wine. On my current medication, one glass gave me a three glass “buzz”. I had a phone call from my insurance company, High Mark Blue Cross Blue Shield, checking to see how I was doing and how was my hospital experience. I told her the CCHS Joint Center was great from admission to discharge. I retired at 10 p.m. requiring my pain medication and Tylenol PM.

Postop Day 10

I had a tough night sleep and required pain medicine every 3 hours. My bed hangs were to just 75 degrees. While I was able to wear TED stockings I could not use my regular compression stockings. I passed the DDD Test and drove for the first time. It was uncomfortable getting into the car. I'm glad it was just a 15 minute trip to my office. I kept 3 car lengths distance, and I did not exceed 35 mph as I recommend to my patients. Prior to leaving, I had done my home exercises and muscle stimulation. At my 10 day office visit, Emma removed my staples. Staple removal does pinch a little. This was the first time that I had been up more than 2 hours. I had to go home and take an hour nap. I had formal physical therapy at UDPT that afternoon with Dr. Melissa Dreger (Fig 36). My flexion to start the PT session was 87 degrees. UDPT performed an MVC at 50%. I was unable to ride the upright stationary bike but I could ride the recumbent bike. I performed the TUG (Timed Up and Go) test and also the driver simulation tests, passing the driving test easily! I left therapy very tired with only 87 degrees of flexion. I retired at 8:30 p.m. after taking my p.m. medications.

Postop Day 11

I had a really tough night sleeping requiring pain medication every 2 to 3 hours. While my incision was not draining it was very scratchy and scaly. I treated it with both Theraworx and Pur 03 four times a day. I continued to massage my thigh with Aspercream and use Llidocaine cream on an area of burning pain below my incision. Both my trochanteric bursitis and my L5 radiculopathy began to become bothersome, and now anterior-medial thigh pain required me to take my pain medication every 3 hours. I was on my feet cooking for 4 hours. I passed my DDD test and drove locally without difficulty. I could shower and sit on the toilet without difficulty. My appetite was improving. I went to the gym in my building and I did 10 minutes on the elliptical level 7, my home exercises, and finished with my muscle stimulation on max, which I had continued to do 3 to 4 times a day.

Postop Day 12

I slept 8 hours that evening awaking just one time, when I took for my pain meds and 2 additional Tylenol PM. My morning bed hangs were to just 75 degrees. My thigh girth continued to be 6 cm larger. My incision looked better with no drainage. While still scaly I applied Theraworx and Pur 03 4 times a day. I had not wear my compression socks nor TEDS on day 11 and I had swelling on the front of my leg. I put on my compression socks with lots of improvement. I did a gym workout to include 2 miles on the elliptical level 7, and did my sit ups. Unfortunately my groin pain and my trochanteric bursitis and L5 radiculopathy were all bothering me at a mild to moderate level. I passed the DDD test and drove and did many errands which included going to the pharmacy to get my renewed pain medication. All totaling 45 minutes. I did my home exercises and muscle stim 2 additional times that day. I took my pain and sleeping medication and retired at 9 p.m.

Postop Day 13

I slept well for 8 hours awaking at 3 a.m. to take 2 additional Tylenol PM and my pain meds. My bed hang was 90 degrees. My incision continued to be less itchy and scaly and I had no drainage. I used the toilet and shower without problems. I continued to do my home exercise program 3 times a day with one exercise bout at the gym which included the elliptical 2 miles at level VII with a heart rate of 130. My Fit Bit did show that I had walked greater than 7000 steps. I was able to flex to 90 degrees with difficulty and had throbbing pain for 1 hour after my forced flexion. I decided to return to using ice and I did so 3 times that day for 30 minutes. My appetite continued to improve. I'd forgotten to take my stool softener on post-op day 12 and suffered the consequences. I had run out of prune juice post op Day 12. There was no reason to drive that day. I took my PM medications and retired at 830 p.m. having taken no naps that day.

Postop Day 14

Again a tough night sleeping awaking at 11 p.m. and 2 a.m. and requiring more pain medication. My morning bed hang was 85 degrees. I showered uneventfully. My appetite was okay. I had a small breakfast of eggs and toast. I took my pain medication and all my other pills I normally take and I went to the gym. I began doing ball stretches (Fig 37) and I was able to flex to 95 degrees. I did a warm-up on the elliptical for 2 miles. My flexion was an easy 95 degrees. I was able to lower the seat on the bike and pedal for 10 minutes on light resistance. I followed this with muscle stimulation continuing on the maximum level. I did my wheelchair stretches and was able to achieve 100 degrees of flexion. I made myself be active for 4 hours in preparation for returning to work for 4 hours to begin in 4 days. I did require a nap. I did my home exercise program 3 more times with muscle stim. I took my p.m. medications and retired at 8:30 p.m. remaining extremely versed on what TV shows and what movies were available. I continued to do my diary with entries twice a day. I did not have to drive that day.

Postop Day 15

I slept well that evening, only awaking at 3 AM when I took two additional Tylenol PM and my pain meds. I showered and used the toilet uneventfully. I exercised at the gym using the elliptical for 10 minutes, did ball bounces, lowered the seat on the bike and pedaled for 10 minutes and easily flexed to 100°.I went to the office for two hours to do some paperwork, ran some errands, and went to physical therapy. It was a breakthrough day. We increased my exercises and following this PT session I was able to flexe to greater than 105°. I returned home and that evening, I did one bout of home exercises and muscle stim. I continued to treat my incision 4 times a day with Theraworx and Pur O3. I took my medication and retired at 9 PM, awaking at 11 PM with my knee and thigh throbbing. I took more pain medication awoke again at 2 AM took more pain medication and slept from 3 AM to 6:30 AM. Again, a good day in therapy with a tough night sleeping.

Postop Day 16

When I awoke, I was able to bed hang at 95 degrees. I took all my AM meds and went to the gym. I repeated my program to include muscle stim. I ate, showered, and used the toilet uneventfully. I passed the DDD test and did 30 min. of driving while doing errands. I dictated my diary up to now on dragon. I did require more pain medication at 4 PM. I had performed my home exercises 3 more times that day and stimmed my quad 3 more times that day. By my Fit Bi, I walked 7000 steps that day. I took my evening meds and retired at 9Pm. I had not used my compression socks that day and did have noticeable swelling on my shin from the base of my incision to my foot.

While I did need more pain meds at 230AM, I did awake feeling rested. I took my AM meds and went to the gym and lowered my bike seat yet again. I ate, showered, dressed, passed the DDD test and drove to work. I saw 17 patients between 8:15-1200. 6 had new problems. My energy level was good. After office hours without resting, I went to UDPT having not taken any pain meds since last evening and still I was not in pain. I left after my 75 min. session with ROM-2to 110 degrees flexion. My thigh girth measurement difference was now just 3 cm. My incision continued to heal without drainage. I used my skin program 3x a day. We had a small dinner party with my daughter and son-in law. I retired at 10 pm without taking any pain medication, but I did need pain meds at 3 AM. I had not required a nap that day. I had consumed several glasses of wine at dinner, perhaps the reason I did not need pain meds until 3 AM.

Postop Day 18

I slept well and felt clear headed. My bed hangs were an easy 95 degrees. I ate, took all of my AM pills and went to the gym. I was able to do the elliptical at level 10 for 2 miles, with a heart rate of just 124. I did my ball bounces and was able to lower the bike seat another level and ride 10 min. I passed the DDD Test and drove to the grocery store, shopped, returned home and cooked for 2 hours. I did 2 sets of home exercises with muscle stim, showered, and went to dinner at my son and daughter-in-law s. I had cut back to just a stool softner on POD 17. I had not had a bowel movement that day and felt “full”and I had a really reduced appetite. I took only Tylenol PM. and slept until 3AM. I took my narcotic pain meds and muscle stim and slept until 5:15AM.

Postop Day 19

I awoke clear headed. My bed hangs were a labored 95. I did muscle stim. I took my AM meds. I was relieved of my full feeling. In my gym program, I advanced to 3 miles at levels 10, maintaining my HR at 120-125. I used a smaller ball for seated bounces, making me flex my knee more. My bike seat was at the same level, but was more uncomfortable to ride more than 5 minutes. I did 4 flights of steps. (40 on my right). It was clear then and on previous days, that if my thigh aches, consider muscle stimulation. I stood cooking for several hours. We attended a NFL playoff event sponsored by the Delaware Chiefs of Police requiring me to ride almost an hour each way to Dover. We left after the first half with my knee feeling stiff. Arriving home, I did my home exercises and muscle stimulation. After watching the first half of the second game, I took my PM meds and retired hoping for a good nights sleep.

Postop Day 20

I awoke at 3 AM, took 2 regular Tylenol, and slept until 5:30AM. I Took my AM meds, did muscle stim and went to the gym and completed my program. I showered, ate, passed the DDD Test, and went to work. Office hours were pleasant and uneventful. I had good energy. I had a meeting at STAR campus and then went to physical therapy. We advanced my program. I was able to bend to more than 110. While I fully expected to attend the DIFCA football banquet, my concern about the hour drive by myself in bad weather, prompted me to not go. I was disappointed but I was not ready to drive at night for an hour in bad weather. I watched TV and took my PM meds and retired at 9 PM.

Postop Day 21

I slept well. I took 2 regular Tylenol at 3AM and slept until 6AM. Bed hangs were an easy 95. I sat and worked on the computer for an hour three times that day, breaking every 15 min to stand and walk about. I went to Wilmington University for my Tuesday night clinic and the my TV show, Youth in Sports taping for an hour. My knee ached at the 30 min mark, forcing me to get up and walk. On the 20 min ride home, my knee was really achy. I took my evening meds and had my best night's sleep since surgery.

Postop Day 22

My Wednesday AM 4 hours of office hours were fine.PT was advanced. I was sore so we tried muscle stim prior to strengthening. I was unable to do single leg extensions with more than 20 lbs. My ROM was 105 prior to leaving. I needed extra pain meds that evening. Driving was getting easier, but I still performed and passed my DDD test before getting in the car.

Postop Day 23

After 4 hours of office, I ran an hour of errands. I then went home to pack for Andrews' Injuries in Baseball course being held in Dallas this year. For the flight we had arranged bulkhead seating for this 4 hour flight.Due to my total knee, I had to go through a special x-ray check despite having TSA clearance. It was easy. After getting on the plane, I put on my pulsating calf sleeves to prevent blood clots. There is a large risk for blood clots when flying after knee surgery. When I looked down, (Fig 39) it looked like I had 2 bombs strapped to my legs. Fortunately the flight attendant had used similar sleeves after her recent knee surgery. She was fine, but boarding passengers who walked by me were not so sure. I had taken pain medication and an extra 325mg aspirin as extra blood thinner, but the trip was still rough despite getting up every half hour to stretch my legs. Once we had arrived at our room, my Fit bit steps were 14, 500. I was tired and sore. My incision was good, no calf swelling, nor calf pain.

Postop Day 24

It was conference day. I exercised for 30 minute to include the elliptical, the bike, open chain leg extensions, and ball bounces. My 7000 steps, plus speaking was no problem. I went to sleep and slept well. My two 30 minute lectures requiring me to stand at a podium went fine.

Postop Day 25

I performed the same exercise program. I sat in conference all day, but still walked 8000 steps.That day, I used stim 4 x at max, and I packed for the early flight.

Postop Day 26 - Return home from Dallas

I had an easy up and travel to the airport. I had bulk head seating on the left side of the plane allowing me to fully extend my right knee. I waited until all the other passengers were on board before applying my pneumatic calf sleeves. I had told the flight attendants about them in advance.. It was a much easier trip. I was the passenger on the ride home. After unloading the car, I exercised for 20 min. My total steps that day were 8000. I only required 3 pain pills that day and my motion was stuck at 0-110 with a fullness deep to my quad tendon and a more sharp pain on both sides of my patellar tendon. I continued to muscle stim at least 3x day, and to wear my knee-high compression socks. I went to bed early. I took my evening meds and slept well.

Postop Day 27 - First Full Office Hour Week

I got up, took my AM meds, no pain meds but 800 mg of Motrin, stimmed and exercised for 30 min. I worked a full 4.5 hour a.m. and 3 hour p.m. office schedule and I had no problems. I recorded 11,000 steps on my Fit Bit, had a better appetite, was taking steps easily up and much better down. My ROM was 0-110. My knee was beginning to feel more a part of me.I did not take any PM meds and slept well awakening only once to void.

Postop Day 28 - Day of Functional Testing

I have been part of arthritis research for years, and another testing time is 4 weeks after TKA surgery. It is the same battery of tests that I took the month before surgery. It included an I-pad questionnaire (Fig 40), measurements of my knee ROM, sit to stand chair test for 30 sec., TUG (which involves rising from a chair walking 10 meters turning around walking back and sitting down ), Stair climbing test (timed walking up and down a flight of steps (Fig 41), 6 min walk for distance (Fig 42), Muscle voluntary contraction test on the Biodex (Fig 43). In addition I did a driving simulation test (Fig 44). I pushed myself and gave the researcher accurate data. While my ROM was 0->110 before the testing, I was <110 after. I purposely had not taken pain meds before the test, but I had planned to and did after the testing. All were pleased with my performance. I took my PM meds and slept well.

Postop Day 29

I did only the elliptical to loosen up. I felt sore in my quad and in my butt, and my ROM was just 105. I had taken Duexis (Ibuprofen and Famotidine) 800mg/26.6mg before bed and took Duexis with breakfast. I was haivng stomach upset from Motrin alone. I did 4 hours of office hours and felt sore and tired. I ran some afternoon errands, did my Wilm U sports clinic, and my TV show. It was a long day. I took my PM meds with pain medication and slept poorly having more butt and thigh pain then truly knee pain, but I was beginning to have a burning pain in my thigh.

Postop Day 30 Return to the Operating Room

I planned my cases for 10:30 AM. One big, and one small. The team and the patients did well, and we were glad to be back together. I was tired. so I went home and took a nap as planned. My butt and thigh were really bothering me, and my ROM was <110. I took pain medications 2X that night, with little improvement, so I made plans for a Piriformis injection and a medral dose pack with Dr. Straight for the next day (Fig 46). I slept poorly again despite PM meds. I attributed my butt and thigh pains to the change in my walking since the correction in my alignment, (my leg was straight and not bowed anymore and I was walking differently, better.)but as I think back, it was probably from the effort I made testing.

Postop Day 31

I awakened with my butt and thigh still hurting. I went to the gym to loosen up with little relief. I completed my AM office hours, and saw Dr. Straight. After an uneventful ultra-sound guided piriformis injection, I went to STAR at UD for an ultrasound evaluation of my knee for fluid to see if it could be restricting my bending with Dr Karin Silbernagle (Fig 48). We concluded that the fluid deep within my joint was limiting me not swelling in the soft tissue between the skin and muscle nor within the muscle. Since I had just had a shot, I cancelled PT that day and did my home stretching program. I began my Medrol dose pack with Vit E to reduce the side-effects from the steroid pills, and Vit B to help with any nerve irritation. I had received a reminder from my dentist for my teeth cleaning. Whoops!!! I had forgotten to do that prior to surgery and now would have to wait at least 3 months. I had been given a Rx for Cephaexin to be taken 1 hour before any dental appointments for the remainder of my life. While some may disagree, I think anyone with a joint replacement should do this simple preventive step. I don't want mouth full of organisms, which have been proven to be circulating in everyone's blood stream after any dental procedure, ending up in my “new knee”. I had a restless night, requiring pain medication.

Postop Day 32

I had arranged for a therapeutic massage for 9AM. After warming up for 10 min, I drove 15 min to Limestone Massage Therapy for a one hour treatment on my involved leg, hip, and back, by Sara Smith (Fig 49). While it took 16 hours for me to tell a difference, it did help. After the treatment, I did 30 min of exercise and then rode 1 ½ hrs. to Lancaster to see my mother. I tried to drive home, but after ½ h. I had to switch to passenger due to thigh and hip and patellar knee pain. After working out after returning home in the gym another ½ hr, my pain was much less. This was my second day on the steroid pack, and I could feel it beginning to work. It was an 8000 step day, and that was enough. I did not require any evening meds and slept for 8 hours, only awakening once.

Postop Day 33 Restoring the house to order 18,000 steps

Due to a ceiling leak in my home from sprinklers being fixed, scaffolding occupied my great room and study for 2 weeks. I had a great deal to clean up. I awoke feeling the best I had since surgery. I drove to the grocery store, shopped, returned home for a 30min. workout, and cooked for an hour. I then cleaned for 4 hrs. Due to my discomfort, I had not pushed my knee flexion and I was stuck at 0-110. I took my pain meds, and went to the gym. After 10 min on the elliptical, I did my ball bounces and started on the bike. I lowered the seat an inch every 5 min (3" total) and hd an easy 0-115 after 15 min. I did muscle stim 4x that day at maximum. My Fit Bit had recorded more than 18,000 steps that day. I watched Brady win in overtime and went to bed only to wake up at 12:30 a.m. to take pain meds. I then slept well until 6AM. After bed hangs, I still had more than 110 degrees of flexion.

Postop Day 34

Office hours began at 9AM, so I had time for good work-out. I kept my 115 of flexion. My 2nd post-op visit was good. My xrays were great and showed no change since the post-op films. My incision was forming keloid in one area and I had pain on the inside of my knee when flexing beyond 110. The conclusion was that it was from the peeling off of the soft tissue to properly make the bony cuts on my tibia and in Dr. Raisis experience, it could last for months. I applied a Rx strength 5% lidocaine patch and RX strength Pennsaid to the sore area and held it in place with co-band. I had used the Pennsaid for almost a month at various local sites of soreness. I finished my PM hours, went home, ate dinner and watched TV. I did 2 sets of muscle stim 3 hours apart and went to bed. I awoke at 2AM in moderate discomfort with my patch fallen off and it was somewhere under the sheets. I took a Tylenol PM and a pain pill and I applied over the counter lidocaine cream to the sore area.

Postop Day 35 5 weeks

I slept until 5: 15 AM. The area on the front of my knee was much less sore. I had a good workout in the gym, ate breakfast, and went to work for a.m. office hours. I went for my second therapeutic massage, to Wilmington University for my clinic, and then did my Youth In Sports TV show taping. I returned home, ate dinner, performed my muscle stimulation, took my PM medications, and slept uneventfully.

Postop Day 36

Nothing new

Postop Day 37-38-Flight to Europe

I woke at 5:30 AM, exercised, showered, performed DDD testing and then drove 30 minutes for an AM. department business meeting. I then drove 20 minutes to the office having both a.m. and p.m. office hours. I returned home and used my muscle stimulator. I went to bed early. I had surgery planned from 7:30 AM to 1 PM the next day. The surgeries went well and I returned home to pack for Europe. At the airport, after using the lounge, the gate was nearly a half-mile away so, we took advantage of the assistance cart. I had already walked 11,000 steps that day. Flying business class, we boarded early, I applied my compression sleeves after informing the flight attendant about what they were, and I slept the next five hours. Due to a long layover in London, I did my muscle stim in the lounge and took 800 mg of Duexis and one pain pill. I felt achy and tired. The two-hour flight to Bologna, Italy was comfortable since I had a bulkhead seat on the left and I was fully able to extend my right knee. We had dinner with friends but were grouped at a small restaurant table with tight seating forcing my knee flexion to be greater than 90°. After 15 minutes it became very uncomfortable requiring me to stand and change seating positions. After the two hours, we walked a short distance home, I took another 800 mg of Duexis and two pain pills, stimulated my quad and slept well. Our hotel was old without elevators and required many stair climbs throughout the two days there.

Postop Day 40

If you're in Italy you have to shop, particularly for shoes, and we did so for four hours. We ate a great lunch in Bologna of pasta and salad, took a nap and dressed for the Catholic wedding. The monastery had tight seating, but I was able to sit on the right side allowing my right knee to be extended travelling to the reception, I sat in the front seat for the 20 minute ride. The three hour wedding reception was fun, but no dancing was involved for me. This was probably a good thing for me. We enjoyed the time spent with the father of the groom. (Fig 50). We left the reception at midnight, knowing a taxi was coming at 4:30 a.m. so we could catch our flight to Copenhagen Denmark.

Postop Day 41

4:30 a.m. came early. My seating on the 7 a.m. flight was bulkhead on the right side of the plane not allowing me to extend my right knee fully. I did get up every 30 minutes to walk about but I was very uncomfortable. After walking through the Copenhagen airport, and then an outside wait for the train to Malmo Sweden, my knee was throbbing. After a short train ride and a short taxi ride, I went to my room, elevated my leg and took a much needed two hour nap. After awakening, I took 800 mg of Duexis and stimulated my quad. I had minimal leg swelling. I felt much better but applied Pennsaid rub to my thigh and shin. We had a pleasant dinner with the consulting committee, and I prepared for the next days activities. I took my p.m. medications and went to sleep.

Postop Day 42

I slept well, ate breakfast and then sat in conference consulting for three hours. We went to Copenhagen for lunch and had an uneventful tour of the city by boat. We returned by train back to Malmo, got take-out dinner, went back to the hotel, packed, and prepared for our 4:45 a.m. taxi to the train station. Our flights took us from Copenhagen to London, with a 3 hour layover, then on to Philadelphia. Upon returning to Newark, we unpacked, and I ran some errands. I slept well suffering no jet lag. Through all this travel, I was still able to maintain my range of motion from 0 to 115, but I did have aching in both my quad and my buttocks similar to what I had had prior to my piriformis injection and Medrol dose pack. It was definitely a nerve issue, probably from coming from my back.

Postop Day 43

I took 800 mg of Duexis and my a.m. pain medication after awakening at 5:15 a.m. I exercised to include 30 minutes on the bike. I showered and went to a full day of Wednesday office hours. I ran some errands after work and returned home tired. I did 2 bouts of muscle stimulation, ate dinner, watched some television and went to bed.

Postop Day 44

I slept well. I exercised, showered, ate breakfast, and went to the operating room for a full day. Completing my schedule at 4 p.m., I came home, ate dinner, and went to sleep. I was exhausted.

Postop Day 45

The 4 hours of office hours were uneventful, and following them, I completed several office tasks, and went to Wilmington University for my clinic. We went to an afternoon movie, and despite spacious seating and the ability to fully extend my right knee, I became uncomfortable after an hour. After a short walk every 30 minutes. I was fine. I was able to sit at dinner comfortably. Returning home, after 15 minutes of muscle stimulation, I felt much better and was able to sleep without difficulty.

Postop Day 46

Restful Saturday of exercise, and game coverage. 13,000 steps on my Fitbit

Postop Day 47

I was able to drive 1 hour each way to and from Lancaster without pain after exercising for an hour.

Postop Day 48-50

Good strength and minimal pain through normal office hours, Wilm U clinic, OR, and TV responsibilities. I required one pain pill each night to sleep due to my thigh and butt pain, not my knee.

Postop Day 51

Full surgery day without any issues. I was neither tired nor in pain.

Postop Day 52

After office hours, I drove an hour to cover Delaware Wrestling States, then I drove home. I slept well without medication.

Postop Day 53

After driving an hour, and working at States-Day 2 for 11 hours, I drove home and was able to sleep without difficulty and without medication.

Postop Day 54-55

Uneventful

Postop Day 56 - 8 weeks to 12 weeks

My knee motion was 0-120 with a push, and my thigh and butt pain remained at a 3 to 7 level.While I had right hip films prior to surgery, the thigh pain concerned me. After 6 weeks of symptoms I had my hip films repeated and they were unremarkable. I then had my first MRI of my lumbar spine. The bones were fine but I had disc and bone spurs pressing on my right L3-L4 nerve roots as they left my spine which could be accounting for my pain in my spine, butt and thigh. I was prescribed another course of Medrol and Vitamin E and began spine exercises and adjusted how I strengthened my quad. I was full activity except for my back limitations. I remain taking flying precautions to include compression socks and aspirin and bulkhead seating on the left side of the plane or flying business again with a left isle seat. My 12 week post-surgery testing is soon.

Perils from my "Experience"

Pre-hab is the beginning of a speedy recovery.

No pillows under the involved knee.

Extremity elevation means above the heart. It is easier if lying on a foot elevated couch or bed.

Home PT is much easier if you live with a Delaware trained P.T. or in my case, a UDPT professor.

Arthritis research done with UDPT is making a difference around the world.

Don't become constipated or you feel "crappy".

Expect to be deconditioned after lying in bed, so schedule return to work and play in a progressive manner.

If crutches are needed, use forearm crutches

Even at 90 days, sleep patterns may remain irregular so consider Tylenol PM and Melatonin.

A simple foot dexterity test gives a good idea about being ready to drive.